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Psychologist treatment recommendations for Internet-based therapeutic

interventions

Article  in  Computers in Human Behavior · September 2008

DOI: 10.1016/j.chb.2008.05.011 · Source: DBLP

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Computers in Human Behavior 24 (2008) 3052–3062

Contents lists available at ScienceDirect

Computers in Human Behavior

journal homepage: www.elsevier.com/locate/comphumbeh

Psychologist treatment recommendations for Internet-based

therapeutic interventions
Louis Mora *, Jeffrey Nevid, William Chaplin
Department of Psychology, St. John’s University, 8000 Utopia Parkway, Queens, NY, 11439, USA

a r t i c l e i n f o a b s t r a c t

Article history: A mailed survey was used to evaluate psychologists’ endorsements

Available online 3 July 2008 of four Internet-based treatment modalities (e-mail, individual
chat, group chat, and video conferencing) as either adjunctive or
Keywords: alternative forms of treatment. Participants were 138 psycholo-
Online therapy gists recruited from a state psychological organization’s member-
Internet ship directory. Participants provided endorsements for each
Psychotherapy
Internet-based intervention based on a hypothetical case in which
Psychologist
past treatment history was manipulated in a randomized design.
Overall, psychologists provided low levels of endorsement of Inter-
net-based services; however, significantly higher levels of endorse-
ment were found for a case vignette that lacked any mention of
past treatment history as compared to an otherwise identical case
that mentioned previous treatment for major depression. Addition-
ally, participants provided higher endorsements for e-mail applica-
tions than other modalities and cognitive-behaviorally-oriented
practitioners more strongly endorsed the use of Internet-based
interventions than psychoanalytically-oriented practitioners.
Ó 2008 Elsevier Ltd. All rights reserved.

1. Introduction

The Internet is a transforming technology in contemporary society, changing everything from mak-
ing travel reservations and ordering concert tickets to accessing medical and psychological sources of
information to social networking. The Internet is also increasingly used to provide various psycholog-
ical interventions, including online counseling and therapy services. As online psychological interven-
tions proliferate, so too do controversies concerning their use.

* Corresponding author. Tel.: +1 718 690 1232; fax: +1 718 990 6705.
E-mail address: louis.mora04@stjohns.edu (L. Mora).

0747-5632/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.chb.2008.05.011
 Author's personal copy

L. Mora et al. / Computers in Human Behavior 24 (2008) 3052–3062 3053

One source of controversy is that mental health professionals, including psychologists, are licensed
in particular states, whereas the reach of the Internet extends beyond state and even international
boundaries. Moreover, ethical and liability issues may arise in the context of psychologists and other
helping professionals providing services to clients they never meet in person and whose identity may
be difficult to verify (Ragusea & VandeCreek, 2003). Many uses of the Internet limit communication to
typed input, which precludes therapists from evaluating nonverbal cues and gestures that may be
reflective of patients’ underlying psychological concerns. Another concern is that online therapists
may live at great distances from clients they treat and so may not be readily available or accessible
in emergency or crisis situations.
Although many challenges facing adoption of online psychological interventions remain, there is an
increasing recognition within the professional community that Internet-based services can have ther-
apeutic value and may require fewer therapist resources than standard face-to-face approaches
(Chang & Yeh, 2003; Litz, Williams, Wang, Bryant, & Engel, 2004; Taylor & Luce, 2003). Internet-based
services may also be able to reach many clients who hesitate to contact helping professionals or who
live in remote areas in which therapist availability is scarce.
Some professionals argue that Internet-based interventions should be used only as an adjunct to
face-to-face psychotherapy (Maheu & Gordon, 2000; Murdoch & Connor-Greene, 2000). Others argue
that stand-alone Internet-based interventions can yield positive outcomes (Chang & Yeh, 2003; Cook &
Doyle, 2002). Psychologists and other helping professionals are presently seeking more responsible
ways of integrating the Internet and other forms of psychotechnology into contemporary clinical
and counseling practice (Comas-Diaz, 2006). Professional organizations such as the American Counsel-
ing Association (American Counseling Association, 2002) and the American Psychological Association
(American Psychological Association, 2002) have also begun to address ethical and legal issues regard-
ing these treatments. Although outcome research on Internet-based psychological interventions re-
mains in its infancy, evidence has begun to accumulate that supports the therapeutic benefits of
these approaches in the treatment of a diverse range of problems including posttraumatic stress dis-
order, panic disorder, social phobia, smoking cessation, weight management, insomnia, and childhood
encopresis (Andersson et al., 2006; Carlbring et al., 2006; Litz et al., 2004; Ritterband et al., 2003;
Ström, Pettersson, & Andersson, 2004; Tate, Wing, & Winett, 2001; Walters, Wright, & Shegog, 2006).

1.1. Internet-based treatment modalities

Internet-based interventions include such modalities as electronic mail (e-mail), video conferenc-
ing, message boards, and chat rooms. E-mail is the most widely used electronic communication
modality between patients and health care providers (Castelnuovo, Gaggioli, Mantovani, & Riva,
2003; Manhal-Baugus, 2001). It allows for asynchronous communication; that is, communication
not occurring simultaneously in real time. Murdoch and Connor-Greene (2000) described using e-mail
to communicate with patients as an adjunct to face-to-face treatment, which included having a de-
pressed patient e-mail homework assignments to the therapist. Yager (2001) reported using e-mail
communications with patients as an adjunctive treatment for eating disorders.
Message boards are also used for the delivery of psychotherapeutic services over the Internet. With
this modality, patients and therapists communicate asynchronously by posting messages to each
other on a message board via a secure website. Chang and Yeh (2003) argued that this modality
can serve either as an adjunct to face-to-face therapy or as an alternative for individuals who may
not feel comfortable receiving services in person.
Message boards and e-mail represent asynchronous forms of communication via the Internet,
whereas, chatting is a synchronous form of communication. Chatting is the most prevalent form of
synchronous communication between patients and mental health professionals (Castelnuovo et al.,
2003). Communication can occur in a chat room via a secure website or by using instant messaging
services. Rhodes (2004) evaluated the use of a chat room intervention for men who have sex with
men in which the therapist moderated conversations regarding HIV prevention; however, lack of a
control group precluded any determination of therapeutic effectiveness.
Like Internet-based chat, video conferencing occurs synchronously and requires scheduling
appointments in advance (Ellevan & Allen, 2004). Currently, most online psychiatric services are
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3054 L. Mora et al. / Computers in Human Behavior 24 (2008) 3052–3062

conducted using video conferencing (Hilty, Marks, Urness, Yellowlees, & Nesbitt, 2004). However,
these services are generally delivered via integrated service digital network (ISDN) or T1 lines, which
involve phone lines rather than the Internet. Use of Internet-based video conferencing has been lim-
ited due to poorer quality, security concerns, and small bandwidth (Maheu, Pulier, Wilhelm, McMen-
amin, & Brown-Connolly, 2005).
A study of 44 online therapy websites run by psychologists provided information on the prevalence
of several Internet-based treatment modalities: e-mail, chat, video conferencing, and message boards
(Heinlen, Welfel, Richmond, & O’Donnell, 2003). Eighty-four percent of the psychologists provided ser-
vices via e-mail and about half via chat. Only nine percent communicated via video conferencing. No
data were collected regarding use of message boards. In another study involving 15 patients who re-
ceived online therapy, 80% communicated with their therapists via e-mail, whereas 20% communi-
cated via chat (Cook & Doyle, 2002). Of those who chatted with their therapists, all communicated
via e-mail as well; however, of those who e-mailed their therapists, only about seven percent also
communicated via chat.
Internet-based treatment modalities differ with respect to their advantages and disadvantages.
Synchronous communication (e.g., chat and video conferencing) allows for more spontaneous interac-
tions, perhaps resulting in the disclosure of more revealing information (Suler, 2000). This type of
communication, however, leaves less room for reflection. Asynchronous communication (e.g., e-mail
and message board) is convenient because appointments do not need to be made in advance; how-
ever, it lacks the spontaneity of synchronous communication. Text-based communication, such as chat
and e-mail, may result in more expressive and honest communications, especially in patients who feel
uncomfortable in face-to-face situations. However, these communications may fail to provide oppor-
tunities for evaluating nonverbal behaviors, which often provide important information about the pa-
tient. Finally, video conferencing allows the therapist to verify the identity of the patient and evaluate
nonverbal behavior, but requires more equipment and technological competence.
The use of message boards was illustrated in an online social support intervention with a sample of
16 Asian American male college students (Chang, Yeh, & Krumboltz, 2001). Across the four-week
intervention, the moderator posted messages thrice weekly, one of which was a discussion of a topic
for that week and the others comprised comments regarding the topic. Self-disclosure increased from
the early to the middle intervention phases, but then tended to decrease towards the end of the inter-
vention. No significant differences were found for collective self-esteem and ethnic identity in com-
parisons of the online group to a control group.
Cook and Doyle (2002) evaluated treatment outcomes as a function of working alliance in a sample
of 15 participants receiving online therapy. Eighty percent of participants participated in an e-mail-
intervention while the remainder participated in a chat group. The Internet-based group as a whole
showed higher scores on a working alliance measure in comparison to a face-to-face group of 25 par-
ticipants. Within the online group, no differences across modalities in the measure of working alliance
were reported. In another exploration of chat-based communication in comparison to face-to-face
communication, participants reported feeling closer and more self-disclosing in a peer face-to-face
communication in comparison to an online chat (Mallen, Day, & Green, 2003). Also, participants in
the face-to-face group exhibited greater levels of both positive and negative affect.

1.2. Attitudes toward online therapy

In addition to treatment studies, data on psychologists’ attitudes toward online therapy will affect
the future of this field. Prior research examined attitudes of psychologists in Norway regarding the use
of Internet-based therapies (Wangberg, Gammon, & Spitznogle, 2007). The authors suggested that on-
line therapy was becoming a popular psychotherapeutic practice in Norway, especially compared to
online therapy use rates in the United States and United Kingdom. Their sample of psychologists
generally maintained neutral stances toward online therapy. Additionally, they reported that psycho-
dynamically-oriented psychologists were less likely to endorse online therapy than cognitively-
oriented psychologists. However, there remains a need to survey opinions of practitioners in other
countries, including the United States, as well to examine factors that may influence opinions of prac-
titioners, such as treatment history of patients.
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1.3. Treatment issues

Issues regarding criteria for determining appropriateness of clients for online therapy and for
matching particular clients to particular Internet-based interventions remain to be resolved. In partic-
ular, questions remain about whether and which types of these interventions are best suited to
patients with different types of psychological disorders. The purpose of the present study was to
examine treatment recommendations by psychologists for various Internet-based treatment modali-
ties as a function of reported patient treatment history and theoretical orientations of respondents. A
mailed survey of members of a state psychological association was used to examine psychologist
endorsements of four Internet-based treatment modalities: e-mail, Internet-based individual chat,
Internet-based group chat, and Internet-based video conferencing. Respondents were asked for
endorsement ratings for each of these online services as both an adjunct and an alternative to face-
to-face treatment.
Participants were presented with the case of a hypothetical patient represented as having been
treated several years earlier for either an anxiety disorder or a major depressive disorder. A neutral
case vignette in which no prior treatment history served as a control. The purpose of this experimental
manipulation was to examine clinician endorsements of online therapy as a function of framing an
identical case description in terms of psychological treatment history for a diagnosable disorder
(i.e., anxiety disorder or major depression). A neutral (i.e., no prior disorder) condition was used as
a control. Moreover, in light of the recent emergence of online psychological interventions, it was ex-
pected that psychologists would more readily endorse use of online therapy services as an adjunctive
treatment than as an alternative to face-to-face treatment.
Because e-mail communication is the most familiar Internet-based modality and the one with the
longest history of use, we expected it would be the most highly recommended adjunctive treatment. It
was also hypothesized that psychoanalytically-oriented psychologists would be less likely to endorse
online therapy than cognitive-behaviorally-oriented (CBT) psychologists, in part because psychoana-
lytic therapists tend to put greater emphasis on the therapeutic relationship and because of their use
of free association. Internet-based interventions that rely on typing responses provide means for cli-
ents to screen or revise their communication prior to transmitting them, which may be seen by psy-
choanalytic therapists as inhibiting access to unconscious material elicited via free association.

2. Method

2.1. Participants

The mailing sample consisted of 450 psychologists listed in the member directory of the New
York State Psychological Association. Participants were selected from among the 2818 members
by use of a random number generator and sorted into three sets of 150. Each set represented a ran-
domly drawn sample for each of three patient vignette conditions (anxious case, depressed case, and
neutral case). The final sample consisted of 138 participants, which yielded a response rate of 31%.
The number of responders across the three vignette conditions did not differ significantly, v2(2) = .39,
p = .82.
Females (n = 76, 55%) comprised the majority of the sample and participant mean age was 54 years
(SD = 11.6). Sixty-eight percent (n = 94) of participants earned their doctorate degrees in clinical psy-
chology, whereas the remaining participants earned degrees in areas such as school psychology (n = 9,
7%) and counseling psychology (n = 8, 6%). In terms of therapeutic orientation, 46 (33%) respondents
identified themselves with CBT; whereas 64 (46%) identified themselves as psychoanalytic. The
remainder of the sample (n = 28, 21%) listed a variety of other orientations.
Although we cannot determine whether the respondent sample was representative of the member-
ship at large, the demographic characteristics and educational backgrounds are comparable to those of
experienced practitioners in the field. The percentages of respondents identifying with a psychody-
namic orientation was somewhat larger than those based on national surveys, which is suggestive
of a continuing strong alliance of New York-based psychologists with psychodynamic training and
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3056 L. Mora et al. / Computers in Human Behavior 24 (2008) 3052–3062

treatment approaches (Nevid, Lavi, & Primavera, 1986). However, we were able to take therapeutic
orientations into account when analyzing endorsements of Internet-based treatment interventions.

2.2. Procedure

Survey participants received a mailed packet that included a cover letter, a self-addressed stamped
envelope, a two-page questionnaire, and a demographic survey form. To preserve anonymity of par-
ticipants, all forms were coded. Individuals requesting survey results were sent a debriefing form fol-
lowing data collection.

2.3. Patient vignette

The questionnaire contained a brief vignette description of a 35-year-old individual who was dis-
satisfied with his or her current occupation and felt a lack of direction in life. No presenting symptom-
atology was reported. However, treatment history was systematically varied. In one condition, the
individual was described as having been treated several years earlier for a major depressive disorder;
in another condition, the individual was described as having been treated for an anxiety disorder. In a
third (control) condition, no statement about past treatment history was included. The vignettes were
identical in all other respects.

2.4. Questionnaire ratings

Participants were instructed to rate their treatment recommendations for each of four online ther-
apy modalities as both an adjunctive treatment and as an alternative treatment to face-to-face therapy
using a five-point scale of endorsement (1 = very unlikely, 2 = unlikely, 3 = possibly, 4 = probably, and
5 = very likely). The four online therapy modalities were: (1) e-mail therapy, (2) Internet-based indi-
vidual chat, (3) Internet-based group chat, and (4) Internet-based video conferencing. Brief descrip-
tions of each of these Internet-based treatment services were provided in the questionnaire.
Additional questions surveyed participants’ attitudes toward nine possible advantages of online
therapy, their willingness to receive training in these techniques and their willingness to use them
in practice. Ratings on these items (e.g.,‘‘Internet-based therapy may help patients who live in rural
areas with limited access to treatment services”) were given on a five-point Likert-type scale
(1 = strongly disagree, 3 = neither, and 5 = strongly agree). Participants also rated their level of concern
about nine aspects of Internet-based therapies (e.g., limits to confidentiality, difficulties verifying the
patient’s identity) by using a five-point scale (1 = not at all concerned, 3 = somewhat concerned, and
5 = extremely concerned). Finally, participants completed a demographic form which requested infor-
mation on gender, psychotherapy orientation, and use of Internet-based technologies in both personal
and professional use.

3. Results

The basic data analytic technique for the hypotheses was multivariate repeated measures analysis
of variance (MANOVA). The multivariate test Wilks’ lambda was used to evaluate effects among within
subjects’ factors. Effect sizes were also calculated.
Prior to the main analyses, we explored relationships between demographic variables (i.e., age and
gender) and endorsement of Internet therapeutic interventions. Gender did not significantly interact
with either Treatment History (Anxiety Disorder vs. Major Depressive Disorder vs. No Treatment His-
tory), Internet Modality (E-mail vs. Individual Chat vs. Group Chat vs. Video Conferencing), or Treat-
ment Use (Adjunct vs. Alternative); however, a significant but unexpected main effect for Gender
was found.
Male participants gave higher levels of endorsements of Internet therapeutic interventions over-
all than female participants. Therefore, gender was used as a covariate in subsequent analysis; how-
ever, because results remained the same, we report results without Gender as a covariate. Age was
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L. Mora et al. / Computers in Human Behavior 24 (2008) 3052–3062 3057

uncorrelated with Internet Modality and Treatment Use with one exception. We found a small but sig-
nificant tendency for older participants to endorse individual chat as an alternative to face-to-face
therapy, r(133) = .19, p = <.05. This correlation was enigmatic to us in the context of nonsignificant
correlations with the seven other endorsements. We are inclined to attribute this finding to chance;
therefore, we did not report age as a covariate in our analyses.

3.1. Effects of vignette condition, modality, and use on endorsements of online interventions

Mean levels of endorsements across Internet modalities and treatment use are reported in Table 1.
Overall, the mean level of endorsement for Internet therapeutic interventions was low (M = 1.48,
SD = .59), with a highest potential rating of five.
A 3  4  2 MANOVA examined Treatment History  Internet Modality  Treatment Use (see Table
2). All analyses maintained alpha at .05. Partial g2 was computed as a measure of effect size. Significant
effects were found for Internet Modality and Treatment Use as well as the Internet Modality  Treat-
ment Use interaction (see Fig. 1). The significant main effect for Internet Modality (p < .01) demon-
strated that video conferencing (M = 1.65, SD = .93) was endorsed more strongly than e-mail
(M = 1.55, SD = .69), individual chat (M = 1.35, SD = .56), and group chat (M = 1.28, SD = .58). The sig-
nificant Treatment Use main effect (p < .01) demonstrated that online interventions were rated more
highly overall as adjuncts (M = 1.67, SD = .80) than as alternatives (M = 1.23, SD = .46) to face-to-face
therapy.
Additionally, a significant (p < .01) interaction of Internet Modality by Treatment Use demonstrated
that participants most highly endorsed video conferencing as an alternative to face-to-face therapy;
whereas, participants most highly endorsed e-mail as an adjunct to face-to-face therapy.
Analysis of the main effect for Treatment History showed that participants in the neutral case con-
dition provided significantly higher (p < .05) levels of endorsement of Internet-based treatments,
M = 1.63, SD = .65, than did participants responding to the major depressive disorder vignette,
M = 1.36, SD = .45. No other differences for Treatment History were significant. Nor did Treatment His-
tory interact significantly with either Internet Modality or Treatment Use.

3.2. Differences between psychologist orientations on endorsements of Internet-based interventions

MANOVA was also used to explore effects of Psychotherapy Orientation (i.e., psychoanalytic vs.
cognitive-behavioral) on endorsements of Internet-based interventions (see Table 3). The analysis
was limited to 110 participants identifying with either of these two major therapeutic orientations.
The results showed, as expected, that psychologists identifying with a CBT orientation expressed

Table 1
Analysis of variance results with vignette as the between-subjects factor

Hypothesis Error Error Wilks’ F p g2

df df MSa kb
Between-subjects effect
1. Vignette Main Effect 2 131 2.63 3.06 0.05 0.05
Within-subjects effects
2. Modality main effect 3 129 0.69 19.07 <.01 0.31
3. Use main effect 1 131 0.67 65.35 <.01 0.33
4. Modality  vignette 6 258 0.96 0.97 0.45 0.02
5. Use  vignette 2 131 0.99 0.62 0.54 0.01
6. Modality  use 3 129 0.72 17.14 <.01 0.28
7. Modality  use  vignette 6 258 0.97 0.60 0.73 0.01
a
The multivariate within-subjects analysis did not calculate mean square values.
b
The between-subjects analysis did not calculate a Wilks’ k value. Vignette, participants received one of three modified case
vignettes; Modality, participants rated use of online therapy across different modes of Internet communication (i.e., individual
chat, video conferencing, group chat, and e-mail); Use, participants rated use of online therapy as an adjunct and alternative to
face-to-face therapy.
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3058 L. Mora et al. / Computers in Human Behavior 24 (2008) 3052–3062

Table 2
Analysis of variance results with orientation as the between-subjects factor

Hypothesis Error Error Wilks’ F p g2

df df MSa kb
Between-subjects effect
1. Orientation Main Effect 1 106 2.52 4.14 0.04 0.04
Within-subjects effects
2. Modality main effect 3 104 0.69 15.50 <.01 0.31
3. Use main effect 1 106 0.66 55.18 <.01 0.34
4. Modality  orientation interaction 3 104 0.96 1.27 0.29 0.04
5. Use  orientation 1 106 0.98 2.18 0.14 0.02
6. Modality  use interaction 3 104 0.72 13.43 <.01 0.28
7. Modality  use  orientation 3 104 0.98 0.55 0.65 0.02
a
The multivariate within-subjects analysis did not calculate mean square values.
b
The between-subjects analysis did not calculate a Wilks’ k value. Orientation, participants were categorized as either
cognitive-behavioral or psychoanalytic based upon their self-reported orientations; modality, participants rated use of online
therapy across different modes of Internet communication (i.e., individual chat, video conferencing, group chat, and e-mail);
Use, participants rated use of online therapy as an adjunct and alternative to face-to-face therapy.

Fig. 1. Endorsements as a function of Internet modality and treatment use.

significantly (p < .05) higher levels of endorsement of Internet-based therapies overall (M = 1.57,
SD = .66) than did psychoanalytically-oriented psychologists (M = 1.35, SD = .48). No significant inter-
action effects were obtained.

3.3. Attitudes toward online therapy

Table 3 presents descriptive data regarding psychologist attitudes toward online interventions. On
the average, respondents agreed with statements that online therapy has value in serving people in
rural areas (M = 3.86, SD = 1.0) and people with disabilities who may have difficult accessing or par-
ticipating in face-to-face therapy (M = 3.75, SD = 1.06). On the other hand, they generally expressed
low levels of interest in using online therapy themselves (M = 2.17, SD = 1.28), even if they received
appropriate training. Nor did they express much interest in receiving training in online therapy if it
were made available. That said, they generally endorsed statements that online therapy will grow
in popularity, that it can provide services to a broader population of people in need, and that it
may help increase therapist caseloads of people who would not be likely to seek face-to-face therapy.
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L. Mora et al. / Computers in Human Behavior 24 (2008) 3052–3062 3059

Table 3
Attitudes about online therapy

Item M SD
1. OT may be more open and expressive than F2F 2.67 1.21
2. OT may help people with disabilities that make it difficult to attend F2F 3.75 1.06
3. OT may help people in rural areas that have difficulty accessing F2F 3.86 1.00
4. OT may help people with busy schedules who have difficulty attending F2F appointments 2.30 1.20
5. OT may provide services to a broader population of people in need 3.06 1.20
6. OT may help people with the stigma of seeing a therapist 2.60 1.25
7. OT may provide therapists with greater flexibility in their scheduling 2.75 1.33
8. OT may help increase therapists’ caseloads of people who would not seek F2F 2.87 1.34
9. OT allows therapists to better monitor patients in potential danger 2.23 1.28
10. Willing to use OT if received appropriate training 2.17 1.28
11. Willing to receive OT training if made available 2.36 1.41
12. OT will grow in popularity 3.43 1.08
13. OT is a fad 2.78 1.07

Note: OT = online therapy; F2F = face-to-face therapy.

Table 4
Concerns about online therapy

Item M SD
1. Expenses involved 1.49 0.85
2. Ensuring confidentiality 4.00 1.19
3. Providing emergency services to patients 3.71 1.27
4. Establishing a strong working alliance 4.07 0.98
5. Technological glitches and failure 3.35 1.23
6. Lack of nonverbal behavior 4.34 0.92
7. Verifying the patient’s identity 3.79 1.27
8. Verifying the therapist’s identity 3.74 1.30
9. Lack of legal guidelines 4.16 1.17

3.4. Concerns about online therapy

Psychologists endorsed a number of concerns about online therapy (see Table 4). On the average,
the highest levels of concern involve the lack of nonverbal behavior (M = 4.34, SD = .92), the lack of
legal guidelines (M = 4.16, SD = 1.17), and difficulties establishing a strong working alliance
(M = 4.07, SD = 0.98). The lowest expressed concern, on the average, was for expenses involved in
online therapy (M = 1.49, SD = .85).

4. Discussion

The present study examined attitudes of members of a state psychological association regarding
the use of Internet-based therapies as either adjunctive treatments or alternative treatments to
face-to-face therapy. Psychologists in our sample did not express strong levels of endorsement of
online therapies as either adjuncts or alternatives to traditional face-to-face therapy, nor did they
express strong interest in using online interventions or receiving training to use these therapeutic
modalities. They did express concerns about the limitations of online interventions with respect to
the lack of accessibility to nonverbal behavior of patients, difficulties establishing working alliances,
and the lack of legal guidelines. On the other hand, the respondents on the average recognized that
online therapy offers some advantages, such as meeting needs of patients in rural areas and patients
with disabilities, who may have difficulty participating in face-to-face therapy.
Not unexpectedly, one of the primary findings was that therapists provided stronger endorsement
of Internet-based therapies as adjunctive treatments than as alternative treatments. These findings
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3060 L. Mora et al. / Computers in Human Behavior 24 (2008) 3052–3062

suggest that online therapy is likely to be better received by professionals when it is integrated within
existing modalities of treatment rather than offered as replacements for traditional therapy.
Treatment history emerged as a factor predicting endorsement of Internet-based therapy. Respon-
dents showed lower levels of endorsement of online therapy for a patient with a history of treatment
for major depression than for one with the same presenting problems but without any representation
of past treatment history. Participants appeared to be more reluctant to recommend novel therapeutic
approaches like online therapy for cases complicated by a history of treatment for major depression,
perhaps because of the need for more personal attention in cases of significant mood disorders.
Findings regarding therapeutic orientation showed, as expected, that cognitive-behavioral practi-
tioners expressed higher levels of endorsement of Internet-based interventions. It is likely that CBT
practitioners will be among the first users of Internet-based modalities to treatment.
As expected, the use of e-mail emerged as the most highly endorsed adjunctive Internet modality.
This finding suggests that e-mail applications may be more readily integrated into contemporary prac-
tice than other forms of Internet-based treatment. Early integration of e-mail applications in clinical
practice may involve submission by patients of homework assignments and perhaps increased oppor-
tunity for patients and therapists to communicate between treatment sessions. In this age of Internet-
capable phones and PDAs, e-mail could also be used for purposes of scheduling or rescheduling
appointments.
Video conferencing received the highest endorsement ratings among the different types of Inter-
net-based therapies as alternatives to traditional face-to-face treatment. One possible explanation
for this finding is that video conferencing most closely approximates in-vivo therapy in that it occurs
synchronously, appointments are made in advance, and therapists and patients have opportunities to
directly see each other. Video conferencing may also help ameliorate concerns about the lack of non-
verbal cues which is inherent in some Internet-based forms of communication, such as e-mail. Partic-
ipants in the present study rated lack of nonverbal cues as their greatest concern about Internet-based
modalities. However, endorsement of video conferencing or other Internet therapies as alternative
treatments is mitigated by the relatively low levels of endorsements for these treatment approaches.
Furthermore, we anticipate that further dissemination of video conferencing and other video tools will
mitigate concerns about accessibility of nonverbal cues in the context of the therapeutic relationship.
The current results are comparable to those of Wangberg et al. (2007) who explored Norwegian
psychologists’ attitudes toward online therapy. Psychoanalytically-oriented psychologists in both
studies rated online therapy lower than cognitively or cognitive-behaviorally oriented psychologists.
Additionally, low response rates characterized both studies. However, their sample generally had
more favorable attitudes toward online therapy, as most of their sample supported the adjunctive
use of online therapy.
An unanticipated gender effect emerged, showing higher levels of endorsement of online therapy
among male respondents than female respondents. This finding parallels research reporting males to
be more frequent and intense users of the Internet (Kennedy, Wellman, & Klement, 2003; Ono & Za-
vodny, 2003; Willoughby, 2008). Although gender was related to the outcome variable, introducing
gender as a covariate did not materially effect the relations between the experimental or predictor
variables and outcome.
Despite the concerns raised about Internet interventions and the general low levels of endorsement
of these modalities, it is important to recognize that online therapies are still in the emerging stage of
development. Experienced practitioners may have little knowledge or experience with these tech-
niques and would understandably be hesitant to endorse them, especially as alternatives to traditional
therapies. Even so, our respondents recognized that Internet therapy is not a fad and is likely to grow
in popularity. Wider dissemination of evidence of the therapeutic efficacy of online interventions may
help raise awareness of the benefits of these techniques among working professionals. However, until
issues regarding legal and ethical implications of these techniques are more formally addressed by
responsible professional associations, it is unlikely these techniques will reach anything approaching
critical mass within the field.
The present findings are limited to a sample of psychologists who are members of a state psycho-
logical association (i.e., New York State Psychological Association). The results may not generalize to
other mental health professionals or psychologists in other states or countries, especially those
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L. Mora et al. / Computers in Human Behavior 24 (2008) 3052–3062 3061

practicing in rural areas in which therapist resources are scarce. Furthermore, task materials were lim-
ited in scope. The materials were constructed to represent a scenario of a hypothetical person express-
ing general dissatisfaction with life and reporting a lack of direction, but without any obvious
presenting symptomatology; therefore, it remains to be studied whether more manifest or severe
pathology would affect clinician perceptions of the viability of online therapeutic interventions. Per-
haps future research would benefit from using Stofle (2001) proposed online therapy level-of-care
model that discusses how pathology severity might affect the appropriateness of online therapy.
Perhaps the most concerning limitation of the study is the relatively low response rate of 31%. A
response rate at this level is typical of research based on mailed questionnaires to psychologist sam-
ples (Gregory & Gilbert, 1992; Wangberg et al., 2007) and is consistent with other studies using this
methodology (Archer, Maruish, Imhof, & Piotrowksi, 1991; Stake & Oliver, 1991). In their survey,
Wangberg and colleagues stated that low response rates may be the result of the unwillingness of
nonresponders to endorse any use of online therapy, which may have reflected Norwegian guidelines
prohibiting the use of e-mail in discussing sensitive health care information. Concerns about the rel-
atively low response rate in the present study may be tempered by the comparability of the present
sample in terms of age, gender, and experience with typical demographic profiles of practicing psy-
chologists (i.e., middle-aged, predominantly female, and with Ph.D.’s in clinical psychology). Nonethe-
less, future research should seek to both increase response rates and understand reasons for
nonresponses.

4.1. Conclusion and future directions

Despite its limitations, the study represents the first empirical exploration of psychologists’
endorsements of online therapy. Generally, psychological professionals appeared unwilling to strongly
endorse online therapies. However, if research further documents therapeutic benefits of online inter-
ventions, these techniques may be become better integrated within mainstream care. A related exam-
ple of another nontraditional therapy is bibliotherapy, which has recently demonstrated treatment
effects comparable to face-to-face therapy for adults with depressive disorders (Floyd, Scogin, McK-
endree-Smith, Floyd, & Rokke, 2004; Gregory, Cannning, Lee, & Wise, 2004). As with bibliotherapy,
the most difficult issue facing online therapy may be the resistance of psychological professionals
in offering this form of therapy, either in the form of an adjunctive or alternative therapy.

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